January bimonthly exam

January bimonthly exam

   

1..Q) Please go through the patient data in the links below and answer the following questions:

26 year old woman with complaints of altered sensorium somce 1 day,headache since 8 days,fever and vomitings since 4 days

More here: https://harikachindam7.blogspot.com/2020/12/26-year-old-female-with-complaints-of.html

Case presentation links: 

https://youtu.be/fz9Jssoc-mA

https://youtu.be/d4lLX04oL8s

https://youtu.be/CSCxw2zp7Oc

a). What is the problem representation of this patient and what is the anatomical localization for her current problem based on the clinical findings?

 1)altered sensorium with irrelevant talk since 1 day

2)neck pain with headache since one month which worsened for the past 8 to 15 days

3)vomitings since one week

4)low grade fever since one week

5)generalised weakness with decreased appetite since one month

anatomical localisation of current problems

Brain-meninges and ?frontal lobe, due to altered sensorium

B)What is the etiology of the current problem and how would you as a member of the treating team arrive at a diagnosis? Please chart out the sequence of events timeline between the manifestations of each of her problems and current outcomes.

The cause for altered sensorium can be attributed to hyponatremia,therefore sodium correction would be done ,

but persistent delirium after correction would probe to considering other causes.

clinical examination - signs

intervention-lumbar puncture

imaging-mri with contrast

https://www.ipinnovative.com/journals/ijirm/article-full-text/8585

Various mechanism have been postulated as how TB can induce hyponatremia, like local invasion to the adrenal glands, local invasion to hypothalamus or pituitary gland, [8][9][10][11] meningitis [12][13][14] and inappropriate ADH secretion due to pulmonary infection [15][16][17], TB can affect adrenal glands directly. TB may destroy adrenals and leading to overt or subclinical adrenal insufficiency and it is one of the most common cause of Addison’s disease in India [2]. The present study was done to study and analyze the prevalence of hyponatremia in adult patients with PTB in tertiary care in India.

one of the cause for siadh could be extrapulmonary tb.

C)What is the efficacy of each of the drugs listed in her prior treatment plan that she was following since last two years before she stopped it two weeks back? 

hcq

https://onlinelibrary.wiley.com/doi/full/10.1002/acr2.11084#:~:text=Despite%20its%20widespread%20use%2C%20only,effect%20on%20survival%201%2C%205.

Of the 509 patients who met inclusion criteria, 66.2% (n = 337) continued HCQ throughout the duration of their treatment (median duration of HCQ treatment was 8.0 years), whereas 33.8% (n = 172) did not (median duration of HCQ treatment was 1.9 years). Patients who received HCQ for less than 1 year before discontinuation (median duration of HCQ treatment was 2.5 months) were more likely to experience SLE flares compared with those who continued HCQ for more than 1 year (13.1% vs 5.7%, P = 0.019). Patients who experienced a flare while on HCQ were more likely to have arthritis, oral ulcers, leukopenia, and thrombocytopenia.

Methylprednisolone

https://pubmed.ncbi.nlm.nih.gov/31323362/

173 patients, 92 CC and 81 BC, were studied. The clinical presentation of both cohorts was similar, with no significant differences in the mean SLEDAI score at diagnosis (6.6 vs. 8.1, p = 0.06). Patients from CC were treated more frequently with hydroxychloroquine (mean 57 vs. 43 months), methotrexate (24% vs. 11%) and pulse methyl-prednisolone (42% vs. 26%), and received lower doses of oral prednisone (average dose during the follow up 2.3 vs. 7.2 mg/d, p < 0.001). Patients in CC were more likely to achieve ClinROnT at year one, 84% vs. 43% (p < 0.001). Prolonged ClinROnT during the 5 years of follow up was more frequent in CC: 70% vs. 28%, p < 0.001. Patients in CC were also more likely to achieve ClinROnT after controlling for baseline SLEDAI (adjusted HR 1.69, 95%CI 1.21-2.35) and for the presenting clinical manifestations (adjusted HR 1.72, 95% CI 1.2-2.4).

alendronate for increasing bone density in gluco corticoid induced osteoporosis

https://pubmed.ncbi.nlm.nih.gov/9682041/

We carried out two 48-week, randomized, placebo-controlled studies of two doses of alendronate in 477 men and women, 17 to 83 years of age, who were receiving glucocorticoid therapy. The primary end point was the difference in the mean percent change in lumbar-spine bone density from base line to week 48 between the groups. Secondary outcomes included changes in bone density of the hip, biochemical markers of bone turnover, and the incidence of new vertebral fractures.

Results: The mean (+/-SE) bone density of the lumbar spine increased by 2.1+/-0.3 percent and 2.9+/-0.3 percent, respectively, in the groups that received 5 and 10 mg of alendronate per day (P<0.001) and decreased by 0.4+/-0.3 percent in the placebo group. The femoral-neck bone density increased by 1.2+/-0.4 percent and 1.0+/-0.4 percent in the respective alendronate groups (P<0.01) and decreased by 1.2+/-0.4 percent in the placebo group (P<0.01). The bone density of the trochanter and total body also increased significantly in the patients treated with alendronate. There were proportionally fewer new vertebral fractures in the alendronate groups (overall incidence, 2.3 percent) than in the placebo group (3.7 percent) (relative risk, 0.6; 95 percent confidence interval, 0.1 to 4.4). Markers of bone turnover decreased significantly in the alendronate groups (P<0.001). There were no differences in serious adverse effects among the three groups, but there was a small increase in nonserious upper gastrointestinal effects in the group receiving 10 mg of alendronate.

Conclusions: Alendronate increases bone density in patients receiving glucocorticoid therapy.

Cholecalciferol

https://pubmed.ncbi.nlm.nih.gov/8782129/

To determine the efficacy and safety of vitamin D 50,000 units/week and calcium 1,000 mg/day in the prevention of corticosteroid induced osteoporosis.

Methods: A minimized double blind, placebo controlled trial in corticosteroid treated subjects in a tertiary care university affiliated hospital. The sample was 62 subjects with polymyalgia rheumatica, temporal arteritis, asthma, vasculitis, or systemic lupus erythematosus. The primary outcome measure was the percentage change in bone mineral density (BMD) of the lumbar spine in the 2 treatment groups from baseline to 36 mo followup.

Results: BMD of the lumbar spine in the vitamin D and calcium treated group decreased by a mean (SD) of 2.6% (4.1%) at 12 mo, 3.7% (4.5%) at 24 mo, and 2.2% (5.8%) at 36 mo. In the placebo group there was a decrease of 4.1% (4.1%) at 12 mo, 3.8% (5.6%) at 24 mo, and 1.5% (8.8%) at 36 mo. The observed differences between groups were not statistically significant. The difference at 36 mo was-0.693% (95% CI -5.34, 3.95).

fluperitine and diclofenac for pain

https://journals.sagepub.com/doi/abs/10.1177/030006058801600503

A controlled, parallel group study of the analgesic efficacy of flupirtine maleate, was compared against diclofenac sodium in 40 orthopaedic patients with post-operative pain. Clinically, both drugs were of equal analgesic efficacy

D)Please share any reports around similar patients with SLE and TB meningitis?

The following is a case report of tb meningitis in a 15yr old girl who is a known case of sle since 4 years 

https://www.researchgate.net/publication/273691193_Tuberculous_Meningitis_in_a_Patient_with_Systemic_Lupus_Erythematosus

Any reports of normal csf leukocyte count and normal csf protein in meningitis? 

https://www.sciencedirect.com/science/article/pii/S1201971213002142

The following table reports, ADA to be more specific in diagnosis of TB meningitis from csf sample, with value greater than 6

Our patient's value of ADA being 9 , rules in favour of tb meningitis

What could be the probable cause for a normal csf leukocyte count in a patient with chronic meningitis? 

e)What is the sensitivity and specificity of ANA in the diagnosis of SLE? 

https://pubmed.ncbi.nlm.nih.gov/8678710/#:~:text=The%20estimated%20sensitivity%20and%20specificity,11%25%20for%20other%20rheumatic%20diseases.

Of 1010 ANA test results reviewed, 153 were positive. The group with positive ANA test results included more patients aged 65 years or older than the group with negative ANA test results (30% vs 15%, P < .003). The diagnosis of systemic lupus erythematosus (SLE) was established in 17 patients, all of whom had positive ANA test results. Other rheumatic diseases were found in an additional 22 patients. The estimated sensitivity and specificity of the ANA test for SLE were 100% and 86%, respectively. For other rheumatic diseases, sensitivity and specificity were 42% and 85%, respectively. The positive predictive value of the ANA test was 11% for SLE and 11% for other rheumatic diseases. Specificity and positive predictive value for ANA testing in the elderly patients were lower than among younger patients.

Q. 2) https://youtu.be/jXVS5J1-RNE

What was the research question in the above thesis presentation? 

The research question 

1)will salt restricted diet decrease blood pressure?

2)can 24hr urinary sodium test reflect the amount of sodium consumed by an individual

What was the researcher's hypothesis?

Hypothesis is that, salt restriction doesn't effect blood pressure in all the individuals in the same way, and salt resistant individuals don't benefit from a restricted diet as much as a salt sensitive individual.

What is the current available evidence for the utility of monitoring salt excretion in the hypertensive population

The 24hr urinary sodium is a reflection of dietary sodium, and has better results than dietary recall method

https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-10/How-to-quantify-salt-intake-in-certain-patients

Daily salt intake based on 24-hour urinary sodium excretion (assuming that all sodium ingested was in the form of sodium chloride) with a formula: figure 2 shows a practical method to estimate salt or sodium intake.

Figure 2: Calculation for estimation of salt or sodium intake

Na (mg/day) = Na (mmol/day) x 23; NaCl = Na (g/day) x 100/ 39,3

1 gram salt (NaCl) = 393,4 mg Na = 17,1 mmol Na

2b)https://youtu.be/sw8o8y5Yw_I

What was the research question in the above thesis presentation? 

The research question in the above thesis is whether magnesium plays a role in complications of diabetes mellitus 

What was the researcher's hypothesis? 

The researcher's hypothesis is that hypomagnesemia causes complications of dm2 irrespective of other confounding factors like age,duration of diabetes.

What is the current available evidence for magnesium deficiency leading to poorer outcomes in patients with diabetes? 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4938107/

In this retrospective study 673 diabetic patients were evaluated. 

According to Mg levels, the patients were divided into two groups; as normomagnesemic patients and hypomagnesemic patients.

There were 55 patients (8.2%) with diabetic retinopathy and 95 patients (14.1%) with diabetic neuropathy. Five hundred patients (74.3%) had normoalbuminuria; 133 patients (19. 8%) had microalbuminuria (MA) and 40 patients (5.9%) had overt proteinuria. One hundred and seventy one patients (25.4%) had HbA1c levels equal or below 7%; and 502 patients (74.6%) had HbA1c levels above 7%. There was no statistical difference in age or duration of diabetes between the groups formed according to Mg levels. Although there were no differences between the groups for retinopathy and neuropathy, MA was more common in hypomagnesemic patients (p =0.004). HbA1c levels did not differ between the groups (p =0.243). However there was a weak negative correlation between serum Mg and HbA1c levels (r =-0.110, p =0.004) and also between serum Mg and urine protein level (r =-0.127, p =0.018

Q. 3)Please critically appraise the full text article linked below:

https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2796.2003.01233.x

What is the efficacy of aspirin in stroke in your assessment of the evidence provided in the article. Please go through the RCT CASP checklist here https://casp-uk.net/casp-tools-checklists/ and answer the questions mentioned in the checklist in relation to your article. 

Clinical appraisal of the article:

1)The study answered the research question 

being the use of asprin for prevention of stroke progression.

it was foccused in terms of intervention given and outcome measured

2)the method for randomisation was appropriate eliminating systematic bias and allocation sequence concealed from investigators and participants

3)all the participants included in the study were accounted for, including rhe two parcels whixh were accidentally opened.

4)the participants and the investigators were blind methodically

5)the study groups were similar 

6)apart from the experimentation, the hospital care given is not documented

7)there were dropouts in the study, study medication was interrupted in few due to suspected side effects,

the p value was not mentioned

8)the cI interval 95%0.6-1.45

9)the treatment effect wasn't much, 

10)the outcomes are benefial to my population in prescribing anticoagulants

dual vs single antiplatelet use and longer duration of followup could have been made .

Q.4. Please mention your individual learning experiences from this month.

Saw this knee patellar clonus for the first time in my Life...

Which was admitted in unit 3 

Saw this hemothorax case in the Casualty which was secondary to RTA

Saw this spotter in the ICU,  dry gangrene in a suspected case of leptospirosis?

Saw this subconjutival hemorrhage in ICU same patient above

Taught interns IJV central catheterization asusual on daily basis during nephro postings 

Performed Lumbar puncture for an intubated case in ICU admitted in unit 1,  45 F suspected TB meningitis patient on mechanical ventilation

Taught an intern pleural tapping procedure which 950 ml was taken from the case of CRF

Taught an intern procedure of ascitic tapping for a  case in CKD was 42y F CKD ON MHD

Experienced the real time change of colour of urine in a patient to orange colour with TB meningitis after the treatment of rifampicin 

I referred myself to ophthalmology for the below lesion found to be an internal hordeolum with a pus point.

Discussion of the below CxR with radiology pgs and Our faculty found interesting findings

Anchovy sauce pus collection seen in a patient with liver abscess.. 

Exploratory emergency laparotomy done I/v/o peritonitis , interesting experience and interesting story behind the same liver abscess case

Esophageal varices patient seen in the gastro OPD 

Cellulitis in a case of CKD on MHD

Cellulitis in a patient with CKD ON MHD 60 F in which fasciotomoy was done

Eager to take this vaccine and waiting for its results

Saw this degloving injury in this patient in Casualty secondary to RTA fall From running lorry

Done thesis presentation in class 2-4 session.

            https://youtu.be/sw8o8y5Yw_I

Saw a classical pain of pancreatitis in the Casualty.. 

Extubation done for 50 y old patient CKD ON MHD 

Q. ,5.)      a) What are the possible reasons for the 36 year old man's hypertension and CAD described in the link below since three years? 

https://vamsikrishna1996.blogspot.com/2021/01/36-year-male-presented-to-casualty-at.html?m=1

The patient is a chronic alcoholic and smoker since 15 years this is the main reason for his hypertension 

b) Please describe the ECG changes and correlate them with the patient's current diagnosis. 

 1st Ecg shows normal axis

But there is an irregularly irregular rhythm

And also there are intermittent broad QRS complexes

Also there is a poor R wave progression but the rhythm in the remaining ecgs seems to be regular 

c) Share an RCT that provides evidence for the efficacy of primary PTCA in acute myocardial infarction over medical management. Describe the efficacy in a PICO format. 

Objectives

The Air Primary Angioplasty in Myocardial Infarction(PAMI) study was designed to determine the best reperfusion strategy for patients with high-risk acute myocardial infarction (AMI) at hospitals without percutaneous transluminal coronary angioplasty(PTCA) capability.

Previous studies have suggested that high-risk patients have better outcomes with primary PTCA than with thrombolytic therapy. It is unknown whether this advantage would be lost if the patient had to be transferred for PTCA, and reperfusion was delayed

Methods

Patients with high-risk AMI (age >70 years, anterior MI, Killip class II/III, heart rate >100 beats/min or systolic BP <100 mm Hg) who were eligible for thrombolytic therapy were randomized to either transfer for primary PTCA or on-site thrombolysis.

Results

One hundred thirty-eight patients were randomized before the study ended (71 to transfer for PTCA and 67 to thrombolysis). The time from arrival to treatment was delayed in the transfer group (155 vs. 51 min, p < 0.0001), largely due to the initiation of transfer (43 min) and transport time (26 min). Patients randomized to transfer had a reduced hospital stay (6.1 ± 4.3 vs. 7.5 ± 4.3 days, p = 0.015) and less ischemia (12.7% vs. 31.8%, p = 0.007). At 30 days, a 38% reduction in major adverse cardiac events was observed for the transfer group; however, because of the inability to recruit the necessary sample size, this did not achieve statistical significance (8.4% vs. 13.6%, p = 0.331).

Conclusions

Patients with high-risk AMI at hospitals without a catheterization laboratory may have an improved outcome when transferred for primary PTCA versus on-site thrombolysis; however, this will require further study. The marked delay in the transfer process suggests a role for triaging patients directly to specialized heart-attack centers.

Source: https://www.sciencedirect.com/science/article/pii/S0735109702018703